Maternity Nursing Q 32
The nurse documents positive ballottement in the client’s prenatal record. The nurse understands that this indicates which of the following?
A. Palpable contractions on the abdomen.
B. Passive movement of the unengaged fetus.
C. Fetal kicking felt by the client.
D. Enlargement and softening of the uterus.
Correct Answer: B. Passive movement of the unengaged fetus.
Ballottement indicates passive movement of the unengaged fetus. Ballottement is when the lower uterine segment or the cervix is tapped by the examiner’s finger and left there, the fetus floats upward, then sinks back and a gentle tap is felt on the finger.
Option A: Ballottement is not a contraction. Contractions can be felt by placing a hand on the abdomen and feeling when the uterus becomes hard, and when it relaxes. It is therefore possible to assess the length of a contraction by taking the time at the beginning and end of the contraction.
Option C: Fetal kicking felt by the client represents quickening. Usually, quickening occurs naturally at about the middle of a pregnancy. A woman pregnant for the first time (i.e., a primigravida woman) typically feels fetal movements at about 18–20 weeks, whereas a woman who has given birth at least once (i.e., a para woman) will typically feel movements around 15–17 weeks.
Option D: Enlargement and softening of the uterus is known as Piskacek’s sign. The Piskacek’s sign is an indication of pregnancy. Specifically, Piskacek’s sign consists of noting a palpable lateral bulge or soft prominence at one of the locations where the uterine tube meets the uterus. Piskacek’s sign can be noted in the seventh to eighth week of gestation.